Republic of the Philippines Department of Health

OFFICE OF THE SECRETARY Bldg. No.1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila 1003

Tel. Nos. (632) 711-95-02, 711-95-03; Telefax No. (632) 743-18-29

ADMINISTRATIVE ORDER No. 2008 - ~0"""0_..2,_,_1 __

July 30, 2008

SUBJECT: Gradual Phase-out of Mercury in all Philippine Health Care Facilities and Institutions

I. RATIONALE I BACKGROUND

Mercury is a naturally occurring heavy metal. At ambient temperature and pressure, mercury is a silvery-white liquid that readily vaporizes and may stay in the atmosphere for up to a year. When released to the air, mercury is transported and deposited globally. Mercury ultimately accumulates in lake bottom sediments, where it is transformed into its more toxic organic form, methyl mercury, which accumulates in fish tissue.

Mercury is highly toxic, especially when metabolized into methyl mercury. It may be fatal if inhaled and harmful if absorbed through skin. Around 80% of the inhaled mercury vapor is absorbed in the blood through the lungs. It may cause harmful effects to the nervous, digestive, respiratory, immune systems and to the kidneys, besides causing lung damage. Adverse health effe~ts from mercury exposure can be: tremors, impaired vision and hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and attention deficit and developmental delays during childhood.

In 1991, the World Health Organization (WHO) concluded that a safe level of mercury exposure, below which no adverse effects, has never been established.

Several European countries Sweden, France, Denmark and Norway, have also banned mercury-containing thermometers from as early as 1991. A European wide resolution on the issue of mercury is pending.

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In the United States, hospitals have significantly reduced the amount of mercury found in facilities and are demonstrating a clear preference for safer alternatives. Many hospitals across the country have taken steps to address the issue, including labeling mercury-containing devices and phasing out their purchase in favor of safer, equally effective alternatives. More than 1,000 hospitals across the US have pledge to virtually eliminate mercury medical device and more than 90% of pharmacy chains have stopped selling mercury fever thermometers. Three of the five largest healthcare group purchasing organizations in the US now have mercury-free purchasing policies ..

On 25 January 2006, at the opening of the first Southeast Asian Conference on Mercury in Health Care held at the Philippine Heart Center, the Department of Health pronounce the gradual elimination of mercury-use in the Philippine health care system.

The Department of Health (DOH) provides the following policies and guidelines for the gradual phase-out of mercury in all Philippine health care facilities pursuant to, among others, the following laws, rules and regulations:

•"Toxic Substances and Hazardous Nuclear Wastes Control Act of 1990" (Republic Act 6969);

•Procedural Manual for Title III: Hazardous Waste Management; • Management of Chemicals and Toxic Substances (Implementing Rules and Regulation for Title II, DENR A.O. 92-29); • "Chemical Control Order for Mercury and Mercury Compounds"

(Implementing Rules and Regulations under DENR A.O. 97-38); • Clean Water Act of2004, (Republic Act No. 9275); • "Policies and Guidelines on effective and proper handling, collection, transport, treatment, storage and disposal of health care wastes", (Joint DOH-DENR Administrative Order No. 02 s 2005) • "Revised Rules and Regulations Governing the Registration, Licensure and Operation of Hospitals and other Health Care Facilities in the Philippines" (DOH Administrative Order 70-A as amended); • Hospital Licensure Act (Republic Act No. 4226) The Consumer Act of the Philippines of the Department of Trade and Industry (DTI), covering various ehemicals, Article 10-Injurious, Dangerous & Unsafe Products (RA 7394)

II. SCOPE AND COVERAGE

These policies and guidelines shall apply to all Health Care Facilities as defined by this document.

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III. DEFINITION OF TERMS

1. Health Care Facilities mean any ofthefollowing:

a. HOSPITALS - places devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity or in need of obstetrical or other medical and nursing care. The term "hospital" shall also be construed as any institution, building or place where there are installed beds or cribs or bassinets for twenty­four hour use or longer by patients in the treatment of diseases, diseased­condition, injuries, deformities or abnormal physical and mental states, maternity cases, and sanitoria! or sanitaria! care infirmities, nurseries, dispensaries, and such other means by which they maybe designated.

b. INFIRMARY - a health facility that provides emergency treatment and care to the sick and injured, as well as clinical care and management to mothers and newborn babies.

c. BIRTHING HOME- a health facility that provides maternity service on pre-natal and post-natal care, normal spontaneous delivery and care of newborn babies.

d. CLINIC - shall mean a place in which patients avail of medical consultations or treatment on an out-patient basis and shall include the following:

d.l Medical d.2 Ambulatory d.3 Dialysis d.4 Health Care Centers and Dispensaries d.5 Surgical d.6 Alternative Medicjne d.7 Dental d.8 Other clinical facilities not mentioned above that require a

license/certification/accreditation from DOH.

2. Mercury- means any substance containing element mercury, either in its pure form, as metallic salts or organometallic compounds.

3. Mercury Audit- A mercury audit aims to identify all the uses and sources of mercury, and the amount present in the facility.

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4. Alternatives to Mercury-containing devices/products- mercury-reduced and mercury­free products that are considered to be viable replacements for mercury-containing devices/products.

5. Hospital Waste Management Committee (HWMC)- means a group in the Health Care Facility with the overall responsibility of ensuring that health care wastes management plan are promoted and implemented.

6. Waste Management Officer (WMO)- means a person in the Health Care Facility responsible for the day-to-day operation and monitoring of the waste management system. In cases where the Health Care Facility has no HCWM, the WMO shall be the person to assume the responsibility of ensuring the health care waste management plan of the facility as promoted and implemented.

7. Mercury Minimization Program- means a gradual phase-out plan for MDEP by a Health Care Facility in accordance with Section V and following the management plan describe in Annex B of this Administrative Order.

IV. GENERAL PROVISIONS

Recognizing the unnecessary risks posed by the continued use of mercury containing products in the healthcare system, the DOH hereby orders that:

1. All Hospitals shall immediately discontinue the distribution of mercury thermometers to patients through the distribution of hospital admission/ discharge kits.

2. All Hospitals shall follow the guidelines for the gradual phase-out of mercury in health care facilities described in this document in the timeline specified.

3. All new Health Care Facilities applying for a License to Operate shall submit an inventory of all mercury- containing devices that will be used in their facilities and a corresponding mercury elimination program.

4. All other Health Care Facilities other than hospital shall make a Mercury Minimization Program based on the guidelines set by this administrative order.

V. GUIDELINES FOR THE GRADUAL PHASE-OUT OF MERCURY IN HEALTH CARE FACILITIES

1. In order to ensure safety and contamination control, steps taken towards mercury elimination in facility must be consistent and predetermined. It is therefore a must to involve the whole facility in a dedicated Mercury Management and Minimization Program, with the goal of:

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a. Raising awareness on the dangers posed by mercury and mercury- containing devices in all health care facilities and institutions.

b. Developing a clear preference for the use of Alternatives to Mercury- containing Devices among health care personnel.

c. In the short term, preventing the further release of mercury to the environment through proper disposal.

2. All Health Care Facilities are hereby tasked to designate a dedicated Mercury Management Team within 2 months from the issuance ofthis order. This team should be directly under the Hospital Waste Management Committee.

For the first 6 months from their inception, the Mercury Management Team should have:

a. Conducted a Mercury Audit of their facility (Refer to Annex "A" Sample Mercury Audit Form). This should include an assessment of the costs of switching to alternatives to mercury-containing devices.

b. Developed and managed a Mercury Minimization Program for their facility (Refer to Annex "B" Sample Mercury Minimization Program)

c. Drafted and implemented a purchasing policy that requires vendors to sign a mercury-content disclosure agreerr:.ent (Refer to Annex "C" Sample Vendor Product Mercury-Content Disclosure) covering products intended for purchase. A clear preference for Alternatives to Mercury-containing Devices where applicable should be in effect. Efforts should be made to communicate with suppliers about an eventual mercury-free purchasing policy and to work with staff on finding Alternatives to Mercury-containing Devices.

d. Conducted a facility-wide information campaign and employee education on the consequences of continued mercury-use. Personnel training on preventing and proper handling of mercury spills should also be accomplished (Refer to Annex "D" How to Handle Mercury Spills)

e. Identified and removed unnecessary practices that promote the use and distribution of mercury-containing medical devices.

3. Within 24 months from the effectivity of this order, all hospitals should have accomplished the following:

a. Fully implemented the Mercury Minimization Program developed for their facility.

b. Switched to alternatives from mercury-containing devices. c. Developed and implemented a program of waste segregation and recycling to

further reduce the mercury waste stream in cases where no alternative products exist. For instance, mercury containing batteries and fluorescent light bulbs should be collected and processed for recycling or should be properly stored.

d. Identified a dedicated mercury collection area within the facility.

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e. Developed a proper temporary mercury storage room in the facility inaccessible to the public (Refer to Annex "E" Guidelines for setting up a Proper Temporary Mercury Storage Area).

f. Incorporated a mercury management module in their training program for new personnel.

g. Information materials on mercury are displayed and/or available in their facility for the benefit of their patients and the general public.

VI. EFFECTIVITY

This order shall take effect 30 days after publication in the Official Gazette and major newspapers and shall supersede all issuance inconsistent therewith.

-f-t,,,~ SCO T. DUQUE III, MD, MSc

Secretary of Health

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ANNIEX "A" Sample Mercury Audit Form

Medical Facility Mercury Survey

This checklist ·is provided as a sample. A checklist can be useful tool to help medical facility staff identify sources of mercury in their workplace. ·

Type of facility (hospital, clinic) . Size of Facility (number of beds, number of Patient visits) Contact Name Title Phone

MERCURY SOURCES

Please indicate the following mercury sources located or used in your facility.

___ Fever thermometers (including home-care visits and those sent home with new borns)

___ Sphygmomanometers ___ Commercial Manometer ___ . Gastrointestinal diagnostic equipment ___ Feeding tubes

Chemicals ___ Zenker's solution .· ,

Staining solution and prese111ativ~s ___ Mercury Chloride ___ Mercury (II) chloride ___ Mercury nitrate ___ Other

___ Histological fixatives·

~-- Mercury (II) oxide ___ Mercury (II) sulfate . ___ Mer~ury iodide

~m~ . __ Fluorescent· __ Metal halide __ High pressure sodium __ Uitr~vioiet

Batteries · Mercuric oxide Button batteries Thermostat Barometers

__ Switches (relay, tilt, silent) . __ Other possi~le mercury sources- please list here any other materials that should

be a concern for mercury pollution.

Have ynu considered mercury-free alternatives for any of the products listed above? ___ Yes No

FACILITY PRACTICES Complete the following section on facility practices. Additional pages may be attached if needed. .,~ ..... ~

. :~). .·: ... : ; ),

·.· ··,)1\ •.

Safety Practices . ~ ... Is staff training provided on the health ancl erwif6nme·ntal concerns of Mercury? __ Yes No ,. ·o··· ··

Is staff training provided on mercury spill prevention or. management? __ Yes __ No If yes, indicate the departments that have this training, and,the frequency.

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Is there a mercury spill clean;.up tool kit on site? ... _ . Yes -~- N9 Have ttiere been any mercury spills within the liiist"ten years2 No __ If Yes, indicate the source of the spill(s) and the cl~an-up rr\ethod:

, .... , ~ '"" ,.

Purchasing Practices

Yes

Does your facility have a policy on purctiasir1'flim'~rcury-~bntaining prod~cts? ·--Yes · No ·. .- , ·'' n~icr:;c(i;<:_ .... > :·.:)·;·:'·

-If-- · yes, please ·..:. .. -· ..... atl~ch · ''- policy.

Does your purchasing department. currently require a disclosure by your vendors of mercury concentrations in chemicals/ reagents? Yes No

Disposal Practices

What is the current proce_dure for disposal of medical waste? __ Autoclave __ Other Have your sewer drain traps or catch basins been cleaned, to remove mercurY.? __ Yes __ No If yes, l~st the area of the facility and dates. _________________ _

Was mercury discovered? Yes No Are any mercury products in your facility currently recycled? __ Yes __ . No Are there ·other facility practices that you think should · be a concern for mercury pollution? List here: ·

Source: "Reducing.Mercury Use in Health Care" www. Sustainable Hospitals. org Original document developed by Western Lake Superior Sanitary District.

ANNEX "B" Sample Mercury Minimization Program

There are several "best management practices" for mercury elimination; these are the procedures that have been found by experience to effectively prevent the release of mercury into the environment. By implementing and effective mercury elimination program now, the health care facilities can help avoid the need for increased regulations in the future. For most mercury-containing products in the health care facility, they preferred best management practice is to replace the item with mercury-free product.

However, it may not be possible to replace all of the health care facility's mercury products at once and, in a few cases, there may not be a substitute that is considered to be reliable and cost effective. For these products, best management practices are effective procedures for handling and environmentally safe management of mercury containing products. Proper mercury recycling facilities, unfortunately, is not yet widely available in the country. Given this fact, proper disposal of mercury should be done through contracted services from the Environment and Natural Resources (EMB-DENR) accredited hazardous waste treaters.

Mercury-containing products can be found almost anywhere in a health care facility. They range from medical instruments and clinical laboratory chemicals to electrical equipment and cleaning solutions.

The following are some of the common mercury containing products in the hospital that can be replaced with mercury-free products available in the market.

FEVER THERMOMETERS

Take-home thermometers; most health care facilities send mercury thermometers home with their patients through their "patient's kit", instead of handing out mercury containing thermometers, hand out mercury-free thermometers instead. The take-home thermometer might be digital or chemical strips. The use of mercury-free alternatives shall prevent the release of mercury to the environment.

If an alternative has not yet been evaluated and chosen, and mercury thermometers must be distributed prior to the stated phase-out dates under this Administrative Order (AO), educate patients on how to safely clean-up (see Annex D) and temporarily store broken mercury thermometers (see Annex E). This can be done easily by handling out written information together with the "patient's kit" or made easily available at the health care facility's pharmacy and information desk.

Keep mercury thermometers out of yellow bags and sharps containers; Mercury volatilizes easily. When mercury thermometer has been placed in a yellow bag

or sharp container that is incinerated or autoclaved, the mercury becomes a gas and enters the air. Mercury that has vaporized in autoclave may also condense along with the ste::1m and enter wastewater. Mercury thermometers should not be placed in yellow bags or sharp containers, even the temporary mercury storage area. The health

care facility's policy or guidelines for the temporary storage area should follow suggested storage procedures. ·

• . d- ~ .... ,H~r. '

Collection and Retrieval of mercury-conta1n7hg,therrnot;rlM.ers.' Develop a policy or guideline for collecting and retrl~vhig u~ed/discarded·mercury­containing thermometers. The used/disca'rded JFi"ermd'meters ·could be placed at a specified collection station that is safe ~nd convenient "for nursing personnel.. The container at the designated collection station shall be :properly marked and labeled. The container could be emptied or picked up on a regular basis or on an as-needed basis, according to the instructions of the waste management coordinator.

SPHYGMOMANOMETERS

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If it is not yet feasil:ile for the health care facil!ty to replace all of its m.~rcury sphygmomanometers, make .sure there is a policy_or g"u1deline for its safe·use and handling. The_ policy or guideline mi"ght include the following instructions:·

• .crt:<ilrY ~f-i''h~aHh ~.-.... ~.. ' ..

1. Check the sphygmomanometer for possible mercury leaks qefore C!;nd after use. 2. Mark the casing or box of SRhygmomanometer witf:)s:.::\e.Gf.il;:!AINS·ME"F{<;;URY:" 3. After every use, safely return the sphygmomanometer to its proper storage. 4. Wear appropriate protective clothing and work within a hood to provide ventilation.

Temporary storage of mercury-containing sphygmomanorjleters Develop a policy or guideline for the preparation of mercury sphygmomanometers for temporary storage that is consistent with (EMB-DENR) 'regulations and other pertinent standards. Contact your waste management committee or officer for details about packaging, labeling and trai1sporting that are specific to your facility. A sugg.ested policy or guideline might include the following instructions:

1. Place the sphygmomanometer in a clear plastic bag and seal the bag. Do not use a yellow bag or biohazard bag.

2. Mark the bag: "CONTAINS MERCURY." 3. Place the bag in a plastic basin to contain any spills during transport to the

designated haz~rdous waste collection point. · ·

Inquire with the health care facility's.suppliers for alternatives to mercury sphygmomanometers, they might f:lave exchange programs and may be willing to take responsibility for one sphygmomanometer per one unit of alternative device purchased from them.

GASTROINTESTINAL TUBES

Temporary storage of mercury-containing gastrointestinal.tubes Gastrointestinal tubes typically have expiration dates, after which its use must be discontinued. Make sure the health care facility has a policy Qr guideline for the handling and temporary storage of mercury-containing tubes that is consistent with standards set by the DENR and other pertinent standards. Contact your waste management committee or officer for details about packaging, labeling and transporting that are

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specific to your facility. A suggested policy or guideline mi'ght include the following instructions:

- .. . ... ,,.,~r. ~:_..},.{-.;\ ~ ·H ,.,

1. Place the tube(s) in a clear plastic bag a[}l:ltse;;tl1the bag. Do not use red. bags or

biohazard bags. · ·' ·:. . " 2. Mark the bag: "CONTAINS MERCURY;" ::-·· .,1,.,,. 3. Place the bag in a plastic basin to contaiilany spills during transport of the tubes to

the designated hazardous waste collection point. ; ·

DENTAL AMALGAM

Many health care facilities do. not have dentaL facilities. However, some health care facilities do haye a clinic within the health care facility or as part of another facility with which they are affiliated. For the benefit of dental clini~~ <;1nd health care facilities that have dental clinics, below..~re some guidelines to follow.

How mercury from dental amalgam can ggt~_nt.qlttJ~ environment? . There are many ways that mercury from dental artralgam can get into the environment:

\ •::-.i<' .:::.~~:-~~{i·.·:~ ... -~ .- . · .. _-·:··f.;.~~-; .. ·.

• If the liquid residues/wastes from dental procedures are di~~~tly con~ectea to a septic system, amalgam particles become part of the sludge in the septic tank, which is eventually pumped out and transported to a wastewater treatment plant or land spread. Any mercury from the amalgam that becomes soluble will end up in groundwater.

• Placing. an item that contains amalgam particles in a yellow bag allows mercury from the amalgam to be releC!sed into the ·air if the waste is autoclaved. The volatilized mercury is then re-depci'sited to the ground or a waterway.

• If items that contain amalgam particles are discarded with the ordinary trash, there is the potential for mercury from. the amalgam to leach into groundwat!3r.when the trash · is placed in a landfill not designed to handle hazardous waste.

• In an older dental clinic,. pure bulk mercury from past practices may have settled in sink traps. The 'mercury is gradually released into wastewater for many years after the use of bulk mercury has bee_n discontinued.

Amalgam storage and handling Stock your amalgam materials in a good choice of capsule sizes, in order to better select the right amount of material for a pa_rticular restoration. This will minimize waste.·

Dental scrap amalgam should be collected and stored in two designated, tightly closed, wide mouth plastic containers. One container should be labeled CONTACT AMALGAM (amalgam that has been in the patients' mouth). The othei should be labeled NON­CONTACT AMALGAM.

Amalgam capsule handling Collect and store the entire contents of broken or unusable capsules with your non­contact scrap amalgam. Even if empty dental amalgam capsules contain no visible amalgam materials, they should be placed in the non-contact scrap amalgam.

If there is a spill of mercury from a capsule, contain it and clean it up imm~diately. Keep

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mercury clean-up materials for treatment and proper disposal. A trained staff me'mber in proper spill. clean-up shall always be available in the health care facility. (SeeAnnex D for Managing Small Mercury Spills). ..,,.,~; "'·

Renovations - . · Alert renovators to the possibility of mercury contamiri'ation in carpets, in floor cracks, behind moldings and other areas where bulk' mercury may have been u~ed, or where ama\~am t.a\)~u\e~ ma'i na'Je bee~ ~\)\\\~d. t\a'Je\\\em CC)~~\l\\ \N\\\\ '{C)\l~ t\ea\\\\ Ca~~ Facility Waste Management Committee or Officer if you have questions about disposal of renovation debris.

FLUORESCENT LAMPS

Mercury in vapor form is contained in fluorescent lamps. The mercury ·that is enclosed in these lamps can be emitted into the' atmosphere whep.they break; are disposed in landfills or incinerated.

Health care facilities generate a considerable amount of s,pent and broken fluorescent lamps. In the absence of a fluorescent lamp recycling facility in the country, proper disposal measures become the priority to eliminate mercury emissions from thi'3 source. Busted and broken fluorescent lamps are considered as hazardous wastes and should be stored temporarily within the health care facility premises or disposed through 'the EMB-DENFX.'s recognized treaters of hazardous wastes.

Collection/Retrieval of Mercury-Containing Lamps There should be designated collection points for spent/busted lamps within.the health care facility. Spent/bustedJamps.from the designated collection points ~liall be taken by the waste management officer to the health care facility's designated temporary storage area. Collected lamps can .be disposed through the EMS EMB-DENR's 'accredited treaters. CAUTION: DO NOT BREAK OR CRUSH THE LAMPS.

In case the lamp is accidentally broken in the health care facility, inform immediately the health care facility waste management officer for proper guidance.

Managing Broken Fluorescent • · Ventilate area where breakage occurred. • Take usual precautions for collection of broken glass. • Do not use a standard vacuum cleaner. Place materials in closed container to

avoid generating dust. • Keep broken lamps in a secure location away frpm patients and s!aff, separate

from the intact tubes.

Storage Option 1: Put used lamps in original boxes with no packing material. Make sure you completely seal the box t6 prevent leaks from bulb breakage. If you are combining used lamps with new ones, mark the used lamps with a piece of tape or a permanent marker (be sure that a marker is located next to receptacle.)

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Storage Option 2: ... Never leave spent lamps unattended or in a compromising position (leaning against ·

a wall or in an area where they can be,,~~~ily brol<:el'l~: · • Do not tape lamps together. · : ·-' 'l ···· ., '·

• Store boxes/co!"'tainers ·in a dry place,__ ._ .. ,. . . • Clearly identify containers of used lamps. For example, ·"used fluorescent lamps for

proper disposal" and the accumt,~lat.ion siart date. You cannot store the used bulbs for longer. than one year.

Energy efficiency of mercury-containing lamps Fluorescent lamps, high-intensity discharge (HIQ):Iamps and ultraviolet lamps (used in biosafety cabinets) are among the few mercury-containing products within.health_care facilities for which adequate non-mercury substitutes do ndt exist.

Fluorescent and HID lamps -are efficient sources of whJt~ Ji'ght, typically 5 times more efficient than incandescen~ lamps. Since fossil fuels contain mercury, power generation releases mercury and other pollutants to the environment, an~ these releases are greater when less efficient lamps are used. Considering both mercury emissions from power generation and mercury contained in the lamps themselves, incandescent 'lamps put more mercury into the environment than do fluorescent lamps.

Know the mercury content of fluorescent and HID lamps and purchase those with relatively low mercury content. In recent years, lamp manufacturers have been reducing the amount of mercury in fluorescent lamps, like in the case of compact'ffuorescent lamps (CFL). Some lamps are low enough in mercury content to be considered non-hazardous for wast_e recycling and disposal purposes. · ·

ANNEX "C" Sample Ve.ndor Product Mercury-Content Disclosul!'e

Hospital Name:

Name of Hospital Purchasing Agent: ........,.. __ ..,..._;. __ ·....,,,?_··,. ___________ _

Address: ____________________________ _

Telephone: _________ _ Fax: ... ~ r"'·

··-~····

The above-named Hospital has the policy of minimizin·g the use of mereury in products purchased for the Hospital. Such products may include:

Barometers Batteries Cleansers and soaps Electrical relays Gastrointestinal tubes Laboratory chemicals Laboratory 11Janometers

Lamps . Pharmaceutical products. Sphygmomanometers Switches Thermometers Thermostat probes · Thermostats ·

Vendorname: ________________________________ ~--------

Name of vendor's agent: ......;_··--------------------------Address:. ____________________________________________ __

Telephone:. ___________ Fax:_· ----------------

The above-named vendor agrees to:

Assist . Hospital in obtaining •manufacturers' disclosures about the mercury content of their products.

Assist --:---.---:---------------------- Hospital i~ selecting products that are virtually free of mercury content.

Signature of vendor's agent Date . .

SOURCE: Reducing Mercury Use in Health Care, www.SustainableHospitals.org

. ANNEX "D" How to Handle Mercury Spills

A Mercury Spill Cleanup Kit can be. used tq_;;qlean .. uP. small mercury_ spills in hqspitals. . Ideally, for medical facilities, one ki.t should be available for every 20 beds. A Mercury · ·· Spill Kit can be purchased or created in-h9u~e,:·The contents of the kit should include:

4-5 zip lock bags Trash bags (2-6 mm thick) Rubber or latex gloves Paper Towels Cardboard Paper Syringe (without needle) Masking or duct tape Flashlight Powdered sulfur (optional) Marker for labeling trash bags and zip lock bags . Small sealable containers for waste mercury. (i.e. empty photo film canister)

Cleanup Instructions

1. Remove all jewelry from hands and wrists so the mercury does not combine (amalgamate) with the precious metals. Change into old clothes and shoes that can be safely discarded should they happen to become contaminated.

2. Remove everyone from the area where cleanup will take piace. Shut door of impacted area. Turn off interior ventilation system to avoid dispersing mercury vapor. ,

3. Mercury can be cleaned up easily from the following surfaces: wood, linoleum, tile and any other like surfaces. If a spill occurs .on carpet, curtain.s, upholstery or other like surfaces, these contaminated items should be thrown away in accordance with the disposal means outlined below. Only cut and rem9ve the affected portion of the contaminated carpet for disposal.

4. Put on rubber or latex gloves.

5. If there are any broken pieces of glass or sharp objects, pick therf! LIP with care.

6. Place all broken objects on a paper towel. Fold the paper towel and place in a zip ·lock bag. S~cure the bag and label it. · ·

7. Locate visible mercur:y bead.s. Use a squeegee or cardboard to gather mercury beads.. Use slow sweeping motions to keep mercury from becoming uncontr9llable. Take a flashlight, hold it at a low angle close to a darkened room and look for additional glistening beads of mercury that may be sticking to the surface or in small cracked ~reas of the surface. · ·

Note: Mercury can move surprising distance on hard-flat surfaces, so search thoroughly. ·

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8. Use the eyedropper to collect or draw up the mercury beads. Slowly and G,arefully squeeze mercury on to a damp paper towel. Place the paper towel in a zip lock bag and secure. Make sure to label the bag. · ,,,,,

9. After you remove larger beads, put shaving crear;n on top of small paint brush · and gently "dot" tlie affected area ,tO picK 'Uf:> smaller hard-to-see beads. Alternatively, use duct tape to C:ollect smaller hard-to-see beads .• Place the paint brush or duct tape in a zip lock bag and secure. Make. sure to label the bag.

10. OPTIONAL STEP: Use powdered sulfur to absorb the beads that are too small to see: The sulfur does two things: (1) it makes the mercury easier to see since the.-e may be a color change from yellow to brown and (2) it binds the mercury and suppressed the vapor of any missing mercury.

Note: When using powdered sulfur, do not breathe in the powder as it can be mqderately 'toxic .

. · ..

11. Place all materials used with the cleanup, including· gloves, in a trash bag. Place all mercury beads and objects into the trash bag. Secure trash bag and label it.

12. Remember to keep the area well ventilated to the outside for at least 24 hours after your successful cleanup. The trash, zip bags and all other materials .used in the cleanup should be storeq and contained in a safe place.

Unfortunately, all we can do right now is to contain the mercury. There is no program yet in the Philippines for its ultimate disposal. You may want, to talk with other realth care · centers, your local government unit, or the Department of Environment and Natural Resour~es to address this. issue of temporary storage and ultimate dispo~al of mercury.

If you neect more information, see: http://www.epa.gov/epaoswer/hazwaste/mercury/faq/spills.htm or the website of the Mercury in Health Care SE Asia Conference: www.mercuryfreeHealth Care.org.

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ANNEX "E" Guidelines fo~ setting up A Proper Tempor-ary Mercury Storage Area

Mercury-containing products not in use must be stored in non-breakable·containers with tight-fitting lids. The containers must be cl.e<:!rly 1.c:1beled as to their contents. Rooms where mercury-containing items are· stored sh.all be tested periodically using a mercury vapor sniffer. Even after most uses of mercury· have' been discontinued in" the hospital, mercury-containing products may still be iii storage from· past uses. All Health care facilities shall check storage areas for old, damaged or outdated equipment.' If mercury­containing products are found, contact the hazardous waste management coordinator. After the removal of the mercury-containing products, the areas shall .be 'checked with .. the mercury vapor _sniffer. ·

Health ·care facilities shall k·eep a permanent record of all materials brought in and out of the mercury temporary storage area. ·

Specific 'storage Requirements and Standards

Storage areas for Mercury and Mercury Compounds or Mercury-bearing or Mercury-contaminated wastes items must meet the following conditions: ·

1. The storage area shall be marked or delineated clearly by fencing, posts, or walls · in order to limit access to it.

2. A recording system on the condition of the storage area shall be established, details of which shall include the observations, name ef inspector, date inspected, etc.

3. The dates when the mercury and mercury-containing materials were· placed in the ·storage area sha'll be indicated on the container and duly recorded.

4. The storage area shall have adequate roof and walls to prevent rain vitater from reaching the mercury anti-mercury-containing material.

5. There shall be no cracks or openings of any kind in the contain111ent floor or walls . that could allow the flow of mercury outside the area.

6. Flo.or of the- storage area must be constructed of impervious material such as ·concrete or-steel, arid if mercury is in liquid form, shall be surrounded by a bund wall to contain spills. ·

7. Visible warning signs ·and notices must be placed in conspicuous areas in the premises.

8. Drainage facilities shall be_ installed in premises where mercury and related compounds are used and handled to contain possible spillage or releases.

9. Emergency showers and eyewash units with adequate water supply shall be made available in premises where mercury and related compounds are used or ·" handled.

10. Fire-fighting facilities shall be in place for use in ca$e of fire/s. . 11. Access to mercury ahd its compounds shall be restricted to those authorized and

. yvith adequate training for such purpose. • 12. A copy of the material Safety Date Sheet shall always. be available in the area. 13. Segregation, adequate ventilation and ideal condition for storage of the chemical

shall be maintained in the area. 14. Ade!quate security sitting and acc:ess to the area shall be observed. 15. Project loading or unloading of containers shall be observed.

16. A workable emergency plan must be in place and impiemented immediately in case of accidental spillage and other emergencies. ·

17. Only trained personnel shall be handling containers in storage as well as in the transport of such substances of mixt~r~s.